A woman was prescribed Effexor-XR 37.5mg capsules by her general
practitioner and presented her prescription at a pharmacy. About
one month later, the woman returned to the pharmacy to collect her
first repeat for Effexor-XR, but was dispensed 75mg capsules
instead of 37.5mg capsules. She brought this to the attention of a
pharmacist who apologised and provided the correct capsules. The
pharmacist did not complete an incident report form at the
time.

Approximately one month later, the woman was prescribed nadolol
40mg tablets. She presented her prescription at the pharmacy the
same day, and collected her medication. It was later discovered
that a second pharmacist incorrectly dispensed the woman
propranolol 40mg tablets.

Approximately two months later, the woman was prescribed
Konsyl-D powder. The woman presented the prescription at the
pharmacy and was dispensed the correct medication by the
pharmacist, but the label did not include the complete dosage
instructions. The computer records were subsequently updated to
document incorrectly that the woman had two repeats available on
the prescription.

One month later, the woman obtained a prescription for further
Konsyl-D powder. She presented her prescription at the pharmacy on
the same day and was incorrectly advised that she had a repeat for
Konsyl-D remaining on her previous prescription. The pharmacist
dispensed the Konsyl-D powder as per her new prescription. The
dosage instructions on the label were consistent with the new
prescriptions but the incorrect prescriber was recorded on the
label.

Approximately one month later the woman collected Konsyl-D from
the pharmacy. The woman was given a repeat, accurately documented
in the pharmacy's computer records as owing from her second
prescription. However, the incorrect prescriber was again recorded
on the label. On this occasion, the woman was also dispensed a
repeat incorrectly documented in the pharmacy's computer records as
owing to her.

It was held that the first pharmacist failed to ensure that he
dispensed the correct strength of Effexor-XR to the woman,
incorrectly labelled the Konsyl-D medication on three occasions,
and failed to complete incident report forms in a timely manner.
Furthermore, by amending the records without ensuring that he kept
a record of those amendments, the pharmacist acted in an
unprofessional and misleading way, and failed to minimise the
potential harm to the woman, contrary to the Pharmacy Council of
New Zealand's Code of Ethics. Accordingly, the pharmacist failed to
provide services that complied with professional standards and
breached Right 4(2).

The second pharmacist failed to ensure that she dispensed the
correct medication to the woman and failed to provide services that
complied with professional standards, and breached Right 4(2).

The pharmacy's failure to ensure staff compliance with its SOPs
played a significant part in the woman receiving the incorrect
medication on two occasions, and her medication being labelled
incorrectly on three occasions. Accordingly, the pharmacy did not
provide services to the woman with reasonable care and skill and
breached Right 4(1). Adverse comment was made with regard to the
pharmacy not having a system in place to ensure that any amendments
to documentation were recorded.